DESCRIPTION: The goal of this three-year study is to evaluate the implications on outcomes and costs of a variety of alternative dialysis initiation strategies. Because a randomized control trial is not feasible, the study will develop simulation models of alternative initiation strategies, and estimate effects on survival, quality of life, rehabilitation, functional status, and costs. Input data for the Monte Carlo simulations will be derived from a variety of sources, including published data, data collected expressly for this study, and existing claims data. Data sources consist of 1) 270 patients in 3 GFR categories drawn from multiple dialysis clinics and several ambulatory nephrology practices in the Bay Area (for aim 2, utilities assessment); 2) 10,000 chronic renal insufficiency cohorts from Kaiser Permanente Northern CA (KPNC) and the San Francisco Community Health Network (for aim 3, demographic and clinical factors associated with outcomes), and 3) multiple HCFA data files from the ESRD program (for aim 4, to determine the best evidence for the effect of dialysis initiation timing, adjusting for selection biases). The final aim of the study is to estimate the feasibility of an RCT of various dialysis initiation strategies, to be achieved by a national survey of 1000 physicians. This is a resubmission of an application reviewed 3/00. The investigators have provided additional preliminary studies and have provided an extensive, detailed example of how the Monte Carlo models will be specified, validated, and optimized.